Abstract
Purpose of Review
The goal of this review is to characterize food allergy management and anaphylaxis in schools and assess current policies and level of preparedness of schools to recognize and treat anaphylaxis.
Recent Findings
An increasing number of school-aged children have food allergies, and studies show that a significant number of school children with no known history of allergies will experience their first anaphylactic reaction at school. Stock-unassigned epinephrine auto-injectors are recommended in schools but not mandatory in most states, and therefore, epinephrine is not always available. Non-nursing staff members are sometimes administering epinephrine due to limitations in nurse staffing.
Summary
Wide variations in staff training and lack of stock epinephrine leave many schools inadequately prepared to manage anaphylactic reactions. Emphasis should be placed not only on ensuring all schools have stock epinephrine but also on training a wider range of school staff members to minimize treatment delay with epinephrine and improve clinical outcomes.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Boyce J, Assa’ad A, Burks A, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(Suppl):S1–S58. doi:10.1016/j.jaci.2010.10.008.
Huang F, Chawla K, Järvinen KM, Nowak-Węgrzyn A. Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes. J Allergy Clin Immunol. 2012;129(1):162–8. doi:10.1016/j.jaci.2011.09.018. e1-3.
Hochstadter E, Clarke A, De Schryver S, LaVieille S, Alizadehfar R, Joseph L, et al. Increasing visits for anaphylaxis and the benefits of early epinephrine administration: a 4-year study at a pediatric emergency department in Montreal, Canada. J Allergy Clin Immunol. 2016;137(6):1888–90. doi:10.1016/j.jaci.2016.02.016.
Tiyyagura GK, Arnold L, Cone DC, Langhan M. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014;18(1):46–51. doi:10.3109/10903127.2013.825352.
Sicherer SH, Sampson HA. Food allergy: epidemiology, pathogenesis, diagnosis, and treatment. J Allergy Clin Immunol. 2014;133(2):291–307. doi:10.1016/j.jaci.2013.11.020. quiz 308.
Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011;128(1):e9–e17. doi:10.1542/peds.2011-0204.
Nowak-Wegrzyn A, Conover-Walker MK, Wood RA. Food-allergic reactions in schools and preschools. Arch Pediatr Adolesc Med. 2001;155(7):790–5.
McIntyre CL, Sheetz AH, Carroll CR, Young MC. Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics. 2005;116(5):1134–40. doi:10.1542/peds.2004-1475.
• Hogue SL, Goss D, Hollis K, Silvia S, White MV. Training and administration of epinephrine auto-injectors for anaphylaxis treatment in US schools: results from the EpiPen4Schools(®) pilot survey. J Asthma Allergy. 2016;17(9):109–15. doi:10.2147/JAA.S106567. A nationwide study during the 2013 to 2014 school year that found significant variability among schools in terms of school staff anaphylaxis training and permission to treat.
Sicherer SH, Furlong TJ, DeSimone J, Sampson HA. The US Peanut and Tree Nut Allergy Registry: characteristics of reactions in schools and day care. J Pediatr. 2001;138(4):560–5. doi:10.1067/mpd.2001.111821.
•• White MV, Hogue SL, Bennett ME, et al. EpiPen4Schools pilot survey: occurrence of anaphylaxis, triggers, and epinephrine administration in a U.S. school setting. Allergy Asthma Proc. 2015;36(4):306–12. Participating schools received free unassigned stock epinephrine auto-injectors, and almost half of anaphylactic reactions were treated with stock epinephrine. A quarter of anaphylactic reactions were not treated with epinephrine. This study highlights the importance of not only keeping stock epinephrine in schools but also educating school staff to recognize and promptly treat anaphylaxis.
Redmond M, Kempe E, Strothman K, Wada K, Scherzer R, Stukus DR. Food allergy prevalence and management at an overnight summer camp. Ann Allergy Asthma Immunol. 2016;116(6):518–22. doi:10.1016/j.anai.2016.03.013.
Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001;107(1):191–3. doi:10.1067/mai.2001.112031.
Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007;119(4):1016–8.
Turner PJ, Gowland MH, Sharma V, Ierodiakonou D, Harper N, Garcez T, et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012. J Allergy Clin Immunol. 2015;135(4):956–63.e1. doi:10.1016/j.jaci.2014.10.021.
Vetander M, Helander D, Flodström C, Ostblom E, Alfvén T, Ly DH, et al. Anaphylaxis and reactions to foods in children—a population-based case study of emergency department visits. Clin Exp Allergy. 2012;42(4):568–77. doi:10.1111/j.1365-2222.2011.03954.x.
Simons FE, Sampson HA. Anaphylaxis: unique aspects of clinical diagnosis and management in infants (birth to age 2 years). J Allergy Clin Immunol. 2015;135(5):1125–31. doi:10.1016/j.jaci.2014.09.014.
Greenhawt MJ, Singer AM, Baptist AP. Food allergy and food allergy attitudes among college students. J Allergy Clin Immunol. 2009;124(2):323–7. doi:10.1016/j.jaci.2009.05.028.
Sampson MA, Muñoz-Furlong A, Sicherer SH. Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol. 2006;117(6):1440–5. doi:10.1016/j.jaci.2006.03.009.
Banerjee DK, Kagan RS, Turnbull E, Joseph L, St. Pierre Y, Dufresne C, et al. Peanut-free guidelines reduce school lunch peanut contents. Arch Dis Child. 2007;92(11):980–2. doi:10.1136/adc.2006.113118.
Bartnikas LM, Huffaker MF, Sheehan WJ, Kanchongkittiphon W, Petty C, Sheetz A, et al. Impact of school peanut-free guidelines on epinephrine administration. J Allergy Clin Immunol. 2014;133(2):AB207.
Hourihane JO, Kilburn SA, Nordlee JA, Hefle SL, Taylor SL, Warner JO. An evaluation of the sensitivity of subjects with peanut allergy to very low doses of peanut protein: a randomized, double-blind, placebo controlled food challenge study. J Allergy Clin Immunol. 1997;100(5):596–600.
Wensing M, Penninks AH, Hefle SL, Koppelman SJ, Bruijnzeel-Koomen C, Knulst AC. The distribution of individual threshold doses eliciting allergic reactions in a population with peanut allergy. J Allergy Clin Immunol. 2002;110(6):915–20.
Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol. 2003;112(1):180–2.
Roberts G, Lack G. Relevance of inhalational exposure to food allergens. Curr Opin Allergy Clin Immunol. 2003;3(3):211–5. doi:10.1097/01.all.0000072719.82112.61.
Perry TT, Conover-Walker MK, Pomes A, Chapman MD, Wood RA. Distribution of peanut allergen in the environment. J Allergy Clin Immunol. 2004;113(5):973–6. doi:10.1016/j.jaci.2004.02.035.
Nguyen-Luu NU, Ben-Shoshan M, Alizadehfar R, Joseph L, Harada L, Allen M, et al. Inadvertent exposures in children with peanut allergy. Pediatr Allergy Immunol. 2012;23(2):133–9. doi:10.1111/j.1399-3038.2011.01235.x.
• Cherkaoui S, Ben-Shoshan M, Alizadehfar R, Asai Y, Chan E, Cheuk S, et al. Accidental exposures to peanut in a large cohort of Canadian children with peanut allergy. Clin Transl Allergy. 2015;2(5):16. doi:10.1186/s13601-015-0055-x. This study found no significant difference in the rate of accidental peanut exposures among peanut-allergic children in schools that prohibited peanut versus those that allowed peanut.
Ford LS, Turner PJ, Campbell DE. Recommendations for the management of food allergies in a preschool/childcare setting and prevention of anaphylaxis. Expert Rev Clin Immunol. 2014;10(7):867–74. doi:10.1586/1744666X.2014.914851.
Centers for Disease Control and Prevention: Voluntary guidelines for managing food allergies in schools and early care and education programs. http://www.cdc.gov/healthyyouth/foodallergies/pdf/13_243135_a_food_allergy_web_508.pdf (2013). Accessed 1 Oct 2016.
American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education: Stepping stones to caring for our children: national health and safety performance standards; guidelines for early care and education programs 3rd edition. http://nrckids.org/index.cfm/products/stepping-stones-to-caring-for-our-children-3rd-edition-ss3/stepping-stones-to-caring-for-our-children-3rd-edition-ss3/ (2013). Accessed 3 Oct 2016.
Massachusetts Department of Public Health, Bureau of Community Health Access and Promotion, School Health Unit: Data health brief: epinephrine administration in schools. http://www.mass.gov/eohhs/docs/dph/com-health/school/epi-data-health-brief-12.pdf (2010). Accessed 3 Oct 2016.
S.1884. School Access to Emergency Epinephrine Act. http://www.gpo.gov/fdsys/pkg/BILLS-112s1884is/pdf/BILLS-112s1884is.pdf. Accessed 3 Oct 2016.
Food Allergy Research & Education: School access to epinephrine map. http://www.foodallergy.org/advocacy/epinephrine/map (2016). Accessed 1 Oct 2016.
Morris P, Baker D, Belot C, Edwards A. Preparedness for students and staff with anaphylaxis. J Sch Health. 2011;81(8):471–6. doi:10.1111/j.1746-1561.2011.00616.x.
• Shah SS, Parker CL, O’Brian Smith E, Davis CM. Disparity in the availability of injectable epinephrine in a large, diverse US school district. J Allergy Clin Immunol Pract. 2014;2(3):288–93.e1. doi:10.1016/j.jaip.2013.09.016. Significantly more schools of lower socioeconomic status had no epinephrine auto-injectors present in the school.
• Greenhawt MJ, Weiss CC. We must create a national policy to protect and manage food allergic students at school. Ann Allergy Asthma Immunol. 2012;109(5):292–4. doi:10.1016/j.anai.2012.08.019. The authors call for a facility-based standardized action plan, unassigned epinephrine in schools, and increased full-time nursing.
Sampson HA, Mendelson LM, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327(6):380–4. doi:10.1056/NEJM199208063270603.
Food Allergy Research & Education: Epinephrine at school. http://www.foodallergy.org/advocacy/epinephrine-at-school (2016). Accessed 1 Oct 2016.
Eldredge C, Patterson L, White B, Schellhase K. Assessing the readiness of a school system to adopt food allergy management guidelines. WMJ. 2014;113(4):155–61.
Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use in schools for food-induced anaphylaxis. J Allergy Clin Immunol. 2016;137(2):AB52. doi:10.1016/j.jaci.2015.12.172.
Sasaki K, Sugiura S, Matsui T, et al. A workshop with practical training for anaphylaxis management improves the self-efficacy of school personnel. Allergol Int. 2015;64(2):156–60. doi:10.1016/j.alit.2014.10.005.
Flokstra-de Blok BM, Dubois AE, Vlieg-Boerstra BJ, et al. Health-related quality of life of food allergic patients: comparison with the general population and other diseases. Allergy. 2010;65(2):238–44. doi:10.1111/j.1398-9995.2009.02121.x.
Lieberman JA, Weiss C, Furlong TJ, Sicherer M, Sicherer SH. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2010;105(4):282–6. doi:10.1016/j.anai.2010.07.011.
Shemesh E, Annunziato RA, Ambrose MA, Ravid NL, Mullarkey C, Rubes M, et al. Child and parental reports of bullying in a consecutive sample of children with food allergy. Pediatrics. 2013;131(1):e10–7. doi:10.1542/peds.2012-1180.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Drs. Tsuang and Wang declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Food Allergy
Rights and permissions
About this article
Cite this article
Tsuang, A., Wang, J. Childcare and School Management Issues in Food Allergy. Curr Allergy Asthma Rep 16, 83 (2016). https://doi.org/10.1007/s11882-016-0663-0
Published:
DOI: https://doi.org/10.1007/s11882-016-0663-0